Forty-five per cent of deaths of children below the age of five globally are attributed to malnutrition, says a study published as part of a compendium of research papers from The Lancet. The study looks at maternal and child undernutrition and overweight in low- and middle-income countries (LMICs) and calls for an enabling environment to tackle malnutrition and incorporate specific nutrition goals and actions.

The authors of the paper led by Robert Black, professor, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, performed a comprehensive analysis of the different causes of maternal and childhood malnutrition, including poor breastfeeding practices and deficiencies of vitamins and minerals such as vitamin A, zinc, iron and calcium. They also analysed the consequences of malnutrition, including stunting (low height for age), wasting (low weight for height), and underweight (low weight for age), all of which result in increased risk of death and illness for both pregnant women and children.

Mother’s health matters

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The research links child mortality to maternal health, with iron deficiency in mothers associated with low birth weight (<2,500g) in babies. Maternal undernutrition also restricts the growth of the baby in the womb and is responsible for a quarter of child deaths. The study finds children born too small–27 per cent in LMICs–are at a substantially higher risk of dying. Maternal short stature and underweight also limit foetal growth and cause 12 per cent of neonatal deaths. Suboptimum breastfeeding too is associated with deaths of more than 800,000 children annually.

According to the researchers, India’s biggest problem is the number of young anaemic mothers–55.8 per cent of adolescents aged between 15 and 19 years and 56.7 per cent of women aged between 20 and 24 years were found to be anaemic. In contrast, corresponding values for Guatemala were 21.0 per cent and 20.4 per cent respectively. Eleven per cent of adolescent girls in India were found to be underweight.

“Currently, only 0.4 per cent of aid is spent combating malnutrition despite it being the leading cause of child deaths,” says Ishaprasad Bhagwat, doctor and health manager with non-profit Save the Children, India.

Stunting still high

The global prevalence of stunting has gradually decreased in the past 20 years, but still remains high in absolute numbers. The researchers estimate that stunting affected at least 165 million children worldwide in 2011. In the same year, at least 50 million children were affected by wasting and 100 million children were underweight. Over 90 per cent of these were in Asia and Africa. Africa is the only major region in the world where the number of stunted children has increased in the past decade.

The authors correlate the prevalence of stunting to equality in different countries. Nigeria showed no change in prevalence of stunting from 2003 to 2008, and the degree of inequality, too, remained almost unchanged. Bangladesh demonstrated a decrease in the prevalence of stunting, though inequality levels remained unchanged. Brazil showed a much lower prevalence of stunting. The researchers thus concluded that equality in the country improved because of a substantial decrease in stunting in the poorest populations.

Obesity brings risks

The research demonstrates that obesity is fast becoming a cause for child undernutrition and mortality. The prevalence of maternal overweight has steadily increased since 1980 and exceeds that of underweight in all regions of the world. Obese pregnant women, whose body mass index is more than 30 kg/m2, are four times more likely to develop gestational diabetes and two times more likely to develop pre-eclampsia. During labour and delivery, maternal obesity is associated with maternal death, haemorrhage, caesarean delivery, or infection; and a higher risk of neonatal and infant death, birth trauma, and macrosomic infants. In the post-partum period, obese women are more likely to delay or fail to lactate and have more weight retention than women of normal weight.

The framework of the report is an improvement on the 2008 conceptual framework of the United Nations Children’s Fund (Unicef), which was also prepared under Black’s lead. The new framework shows the dietary, behavioural and health determinants of optimum nutrition, growth and development. It analyses how they are affected by policies related to food security, care giving resources and environmental conditions. Apart from immediate reasons related to maternal and bodily health of a child, the new framework also encompasses “economic and social conditions, national and global contexts, resources, and governance”.

The paper has been published in the Lancet series on maternal and child nutrition 2013 that was released on June 6.